Information Collection

Medical Travel Refund Request

IC 38444 under ICR 202601-1240-002 · OMB 1240-0037.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-957A Medical Travel Refund Request	Form and Instruction
Form OWCP-957A Medical Travel Refund Request - Mileage Medical Travel Refund Request	Form and Instruction
Form OWCP 957B Medical Travel Refund Request - Expenses Medical Travel Refund Request	Form and Instruction
OWCP-957A Medical Travel Refund Request - Mileage 1240-0037 Medical Travel Refund Request - Mileage (OWCP-957A).docx	Form and Instruction
OWCP-957A Medical Travel Refund Request - Mileage 1240-0037 Medical Travel Refund Request - Mileage (OWCP-957A).docx	Form and Instruction
OWCP 957B Medical Travel Refund Request - Expenses 1240-0037 Medical Travel Refund Request - Expenses (OWCP-957B).docx	Form and Instruction
OWCP 957B Medical Travel Refund Request - Expenses 1240-0037 Medical Travel Refund Request - Expenses (OWCP-957B).docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.406 20 CFR 30.404 20 CFR 10.315 20 CFR 725.701

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-957A				Yes	No	Fillable Printable
Form and Instruction	OWCP 957B				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/GOVT-1 (FECA)

FR Citation: 81 FR 47418

Number of Respondents: 37,132

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	356,875	356,875
Annual IC Time Burden (Hours)	53,531	53,531
Annual IC Cost Burden (Dollars)	239,106	239,106

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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